Application for Moonshot Magic Mastermind

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* 1. Resourcefulness: In the last 12 months, how many times did you reach out for support to get care for yourself? (massage, therapy, coaching, etc.)

None

5 to 9

10 or more

Other (please specify)

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* 2. Demographics: Please submit

Name *

City/Town

State/Province

Country

Email Address *

Phone Number

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* 3. Struggles: What keeps you up at night?

a deep sense of overwhelm, too much stress

discomfort, physical pain

lack of trust and respect in my life

not enough time or energy to give to my family, my lover, or my Self

lack of Spiritual connection and greater calling

lack of stability, security, safety

lack of adventure, mystery, ecstasy

none of the above fit

more than one of the above, answer in "other" space below

Other (please specify)

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* 4. Clarity: What relationship are you most eager to invest time and energy into now?

Relationship with myself (resolving negative thinking, sealing energy leaks, reclaiming power and self-sovereignty)

Relationship with my partner (quality time, resolving negativity, pursuing dreams together)

Relationship with Spirit (praying, meditating, allowing space for grace to enter)

Relationship with Surroundings (cleaning up household, tending to garden, projects to better the environment)

Relationship with Society (boss, friends, associates, volunteer interests)

Other (please specify)

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* 5. Declaration: I'm ready, willing, and able to invest in my relational health, declare my Moonshot (aim high, dive deep, and live an extraordinary life)

I'm not ready

I'm ready and willing, not able to presently

I'm ready, willing and able yet I tell myself it's impossible

I'm ready, willing and able and still have questions

I'm ready, willing and able now 100%

I'm not ready

I'm ready and willing, not able to presently

I'm ready, willing and able yet I tell myself it's impossible

I'm ready, willing and able and still have questions

I'm ready, willing and able now 100%

Other (please specify)

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* 6. Commitment: I'm committed to change in here to ignite out there. I know personal transformation is an inside job and there are things I want to be different in my environment (home, family, community, world) but it starts within.

I disagree completely

I agree somewhat but not entirely

I agree and yet I still try to change others

I agree wholeheartedly yet I don't know how to do it

I agree wholeheartedly. I'm ready to commit 100%

I disagree completely

I agree somewhat but not entirely

I agree and yet I still try to change others

I agree wholeheartedly yet I don't know how to do it

I agree wholeheartedly. I'm ready to commit 100%

Other (please specify)

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* 7. Committed Action: I'm clear that writing down my intentions, stating my declarations (Moonshots), makes them more likely to happen.

0 This isn't me

50 I know this, I haven't done it up until now

100 I know this to be true in my life, 100%

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. Accountability: I'm aware that sharing my Moonshot with others, after writing them down, increases the likelihood they will happen

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 9. Mastermind Readiness: I'm ready, willing, and able to be accountable to others and provide valuable feedback to others to enhance accountability and inspiration. We rise together

neutral

100

Clear

i We adjusted the number you entered based on the slider’s scale.